The new mother asks the nurse about the presence of a small blood-tinged area on her daughter's diaper. Which response by the nurse would be most accurate?

"It is possible that your baby experienced birth trauma that has caused some bleeding"

"Your baby has an infection that will need to be evaluated by the physicians

"Breastfed babies often experience this type of bleeding problem due to lack of Vitamin K in the mother's milk"

"Some female infants experience menstruation like symptoms as a result of the mother's hormones

Answer and Explanation

The Correct Answer is D

A. "It is possible that your baby experienced birth trauma that has caused some bleeding." While birth trauma can cause bleeding, it is not the most common cause of a small blood-tinged area in a newborn's diaper, particularly in female infants. Trauma-related bleeding would typically be more noticeable or involve more significant injury.

B. "Your baby has an infection that will need to be evaluated by the physician." This statement is unlikely, as the presence of a small amount of blood-tinged discharge in a newborn’s diaper is not typically a sign of infection. Infection would present with other symptoms, such as fever, irritability, or abnormal discharge.

C. "Breastfed babies often experience this type of bleeding problem due to lack of Vitamin K in the mother's milk." This is incorrect. Newborns are given a Vitamin K injection shortly after birth to prevent bleeding issues (such as Vitamin K deficiency bleeding). Lack of Vitamin K in the mother's milk is not a cause of blood-tinged discharge in female infants.

D. "Some female infants experience menstruation-like symptoms as a result of the mother's hormones." This is the correct response. A small amount of blood-tinged vaginal discharge (often described as pseudomenstruation) in female newborns is common and occurs due to the influence of the mother's hormones (mainly estrogen) passed to the baby in utero. It typically resolves within a few days to weeks and is considered a normal physiological response.

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Correct Answer is D

Explanation

A. Deficient fluid volume is not the priority concern at this time. While newborns are at risk for dehydration, there are no indications in the assessment (such as dry mucous membranes or poor feeding) that would suggest deficient fluid volume as the immediate priority.

B. Risk for infection is a concern for all newborns, especially in the first hours of life. However, the information provided does not suggest signs of infection such as fever, lethargy, or abnormal skin color.

C. Impaired parenting may be a concern later on if the parents show difficulty bonding or caring for the infant. However, this is not the immediate priority based on the infant's current assessment.

D. Hypothermia is the priority. The infant’s axillary temperature of 95.8° F (35.4° C) is below the normal range for a newborn, which is typically between 97.7° F (36.5° C) and 99.5° F (37.5° C). Hypothermia in newborns can lead to complications such as respiratory distress, metabolic instability, and increased risk for infection. Immediate interventions, such as warming the infant and ensuring a warm environment, are necessary to prevent further complications.

A. 8.4 mEq/L B. 6.1 mEq/L C. 10.8 mEq/L D. 3.3 mEq/L

Correct Answer is B

Explanation

A. 8.4 mEq/L is above the therapeutic range and may indicate magnesium toxicity. Levels greater than 7.5–8 mEq/L can lead to loss of deep tendon reflexes, and higher levels can cause respiratory depression and cardiac arrest.
B. 6.1 mEq/L falls within the therapeutic range for magnesium sulfate when used to treat severe preeclampsia, which is generally 4.8–8.4 mEq/L (or 4–7 mEq/L depending on the source and unit of measurement). This level is considered safe and effective for preventing seizures.
C. 10.8 mEq/L is too high and indicates magnesium toxicity, placing the patient at risk for serious complications like respiratory or cardiac arrest.
D. 3.3 mEq/L is below the therapeutic range, suggesting that the dose may be inadequate to prevent eclamptic seizures in a woman with severe preeclampsia.

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The new mother asks the nurse about the presence of a small blood-tinged area on her daughter's diaper. Which response by the nurse would be most accurate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

Correct Answer is D

Explanation

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?

Correct Answer is B

Explanation

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